Fee Schedule

The pharmacy fee schedule is based on Wolters Kluwer Medispan Electronic Drug file wholesale acquisition cost (WAC) or the organization's pharmacy benefit management company's maximum allowable cost (MAC), when applicable.

GENERIC MEDICATION FEE SCHEDULE
  • The lesser of maximum allowable cost (MAC) plus 5% or WAC plus 8%, plus a single per item dispensing fee of $5.00 or usual & customary (URC) pricing
    • MAC pricing is based on the most current MAC list provided by WSI's PBM
  • Reimbursement is the lesser of billed charges or the fee schedule amount
BRAND MEDICATION FEE SCHEDULE
  • Reimbursement is at the WAC plus 8%, plus a single per item dispensing fee of $4.00; or the UCR pricing
  • Reimbursement is the lesser of billed charges or the fee schedule amount
COMPOUNDED PRESCRIPTION FEE SCHEDULE

Compounded prescriptions are reimbursed at the average wholesale price (AWP) minus 72%, plus a single item compounding fee based on the following level of effort (LOE) level or the UCR pricing:

 Compound LOE  Value  Reimbursement

 Level 1

 Mixing liquids using graduated cylinders

 11  $ 10.00

 Level 2

 Triturate powder and mix by geometric

 dilution, mix creams, ointments, emulsions

 and liquids by hand or by using unquator

 12  $ 15.00

 Level 3

 Suppository mold, lollipop mold and

 troche/mini-trouche mold, dissolve powder

 using stirrer and hot plate, melt base on hot

 plate, burette and/or pH meter, making

 capsules using filling machine

 13  $ 20.00

 Level 4

 USP 797, sterile compounding using hood

 14  $ 25.00